Transplant safety has improved for patients with diabetes

SAN DIEGO – The risks for patients with diabetes who face organ transplants have diminished greatly, according to an endocrinologist.

But there are still many limitations for these patients – some transplants are not appropriate for patients with diabetes – and there are potential complications when they do get transplants.

“While it used to be that outcomes were worse in patients with diabetes, such as more infections and higher mortality, this has become much less so over time, because of team-based care and better focus on diabetes management postoperatively,” said Jennifer Larsen, MD. Still, “the complexities come with the variable other factors and conditions the patient might have, such as autonomic neuropathies, the sudden variations in kidney function that can occur before and after transplant, and the impact of the transplant medications on other aspects of diabetes care such as lipid management and metabolism of other drugs.”

Dr. Jennifer Larsen

Dr. Larsen’s presentation at the annual scientific sessions of the American Diabetes Association focused on kidney, pancreas, and islet transplants, but she said in a follow-up interview that endocrinologists should be familiar with the transplant world as a whole.

“They also take care of diabetes patients who get other types of transplant such as heart transplant, liver, and lung,” said Dr. Larsen, vice chancellor for research and professor of internal medicine at University of Nebraska Medical Center, Omaha.

And, she added, they take care of patients who develop diabetes after transplants – posttransplant diabetes. “So it’s important to the endocrinologist today to be familiar with the transplant world, the medicines used, and how chronic kidney disease impacts diabetes management,” she said.

Endocrinologists serve in a variety of roles when patients need transplants, she added. “In some cases the transplant surgeon is referring to us, the endocrinologist. If the patient is heading toward kidney transplant in particular, the pancreas and islet options with kidney transplants would all be handled by the transplant nephrologists, who work hand in hand with the transplant surgeons. Some endocrinologists are embedded in these teams, too.”

Patients with diabetes complicated by chronic kidney disease may be eligible for a transplant of a kidney – in line with the adage that “any kidney is better than dialysis,” Dr. Larsen said – or kidney/pancreas or kidney/islet transplants.

Kidney/pancreas and kidney/islet transplants may be performed simultaneously or with the kidney transplant first. However, islet transplants are not appropriate for patients with type 2 diabetes, and these patients also may not be eligible for simultaneous kidney/pancreas transplants.

According to the United Network for Organ Sharing, there were more than 415,075 kidney transplants from Jan. 1, 1988, to June 30, 2017 (www.unos.org/data). The numbers for pancreas and kidney/pancreas transplants are 8,462 and 22,496, respectively. Islet transplant numbers were not available.

Five-year patient survival rates for kidney transplants are 85%, and graft survival rates are 71%, Dr. Larsen said, and they’re similar for kidney/pancreas transplants. According to Dr. Larsen, patient survival is lower after islet transplantation.

Diabetes complications can affect patient eligibility for these kinds of transplants, Dr. Larsen said, and weight can be a complicating factor. The drugs used in transplants in patients with higher body mass indexes exacerbate insulin resistance, Dr. Larsen said, “and that will make it harder to manage afterward. We haven’t worked out if BMI affects graft function over time.”

Reduced cardiac function eliminates simultaneous pancreas/kidney (SPK) transplants as an option for patients with diabetes, while blindness, severe hypoglycemia unawareness, and other autonomic neuropathies can make SPK more appropriate. Gastroparesis, meanwhile, can be an issue for all transplants.

Dr. Larsen’s own research has suggested that SPK transplants can be better than kidney transplant alone in terms of improving neuropathy, symptoms of peripheral neuropathy, and, perhaps, gastroparesis symptoms. However, SPK is not better in terms of improving bladder neuropathy, eye disease, amputations, and cardiac complications of diabetes (Endocr Rev. 2004;25[6]:919-46).

While the prognosis for transplants in diabetes patients is often promising Dr. Larsen cautioned that there can still be a big obstacle: Primary care physicians who fail to act.

“Most diabetes patients are not managed by endocrinologists,” she said, “and there are still many primary care physicians who delay referral to transplant teams for their diabetes patients or even to endocrinologists when they are struggling with diabetes management.”